Description :

Establish effective care coordination and active referral management that could include one or more of the following: Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements; Track patients referred to specialist through the entire process; and/or Systematically integrate information from referrals into the plan of care.

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_10 Care transition documentation practice improvements

Description :

Implementation of practices/processes for care transition that include documentation of how a MIPS eligible clinician or group carried out a patient-centered action plan for first 30 days following a discharge (e.g., staff involved, phone calls conducted in support of transition, accompaniments, navigation actions, home visits, patient information access, etc.).

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_11 Care transition standard operational improvements

Description :

Establish standard operations to manage transitions of care that could include one or more of the following: Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/or Partner with community or hospital-based transitional care services.

Subcategory Name :

Activity Weighting :

Description :

Membership and participation in a CMS Partnership for Patients Hospital Improvement Innovation Network.

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_3 Implementation of additional activity as a result of TA for improving care coordination

Description :

Implementation of at least one additional recommended activity from the Quality Innovation Network-Quality Improvement Organization after technical assistance has been provided related to improving care coordination.

Subcategory Name :

Care Coordination

Activity Weighting :

Description :

Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_2 Implementation of improvements that contribute to more timely communication of test results

Subcategory Name :

Activity Weighting :

Description :

Implementation of practices/processes to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s).

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_1 Implementation of use of specialist reports back to referring clinician or group to close referral loop

Description :

Performance of regular practices that include providing specialist reports back to the referring MIPS eligible clinician or group to close the referral loop or where the referring MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the certified EHR technology.

Subcategory Name :

Care Coordination

Activity Weighting :

Description :

Ensure that there is bilateral exchange of necessary patient information to guide patient care that could include one or more of the following: Participate in a Health Information Exchange if available; and/or Use structured referral notes.

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_14 Practice improvements that engage community resources to support patient health goals

Description :

Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following: Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and/or Provide a guide to available community resources.

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_7 Regular training in care coordination

Description :

Implementation of regular care coordination training.

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_4 TCPI participation

Description :

Participation in the CMS Transforming Clinical Practice Initiative.

Subcategory Name :

Care Coordination

Activity Weighting :

High

#IA_CC_6 Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination

Description :

Participation in a Qualified Clinical Data Registry, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (e.g., documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups).

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_1 Implementation of Use of Specialist Reports Back to Referring Clinician or Group to Close Referral Loop

Description :

Performance of regular practices that include providing specialist reports back to the referring individual MIPS eligible clinician or group to close the referral loop or where the referring individual MIPS eligible clinician or group initiates regular inquiries to specialist for specialist reports which could be documented or noted in the EHR technology.

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_2 Implementation of improvements that contribute to more timely communication of test results

Description :

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_3 Implementation of additional activity as a result of TA for improving care coordination

Description :

Implementation of at least one additional recommended activity from the Quality Innovation Network-Quality Improvement Organization after technical assistance has been provided related to improving care coordination.

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_4 TCPI Participation

Description :

Participation in the CMS Transforming Clinical Practice Initiative

Subcategory Name :

Care Coordination

Activity Weighting :

High

#IA_CC_5 CMS partner in Patients Hospital Engagement Network

Description :

Membership and participation in a CMS Partnership for Patients Hospital Engagement Network.

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_6 Use of QCDR to promote standard practices, tools and processes in practice for improvement in care coordination

Description :

Participation in a Qualified Clinical Data Registry, demonstrating performance of activities that promote use of standard practices, tools and processes for quality improvement (e.g., documented preventative screening and vaccinations that can be shared across MIPS eligible clinician or groups).

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_7 Regular training in care coordination

Description :

Implementation of regular care coordination training.

Subcategory Name :

Care Coordination

Activity Weighting :

Description :

Implementation of practices/processes that document care coordination activities (e.g., a documented care coordination encounter that tracks all clinical staff involved and communications from date patient is scheduled for outpatient procedure through day of procedure).

Subcategory Name :

Care Coordination

Activity Weighting :

Description :

Implementation of practices/processes, including a discussion on care, to develop regularly updated individual care plans for at-risk patients that are shared with the beneficiary or caregiver(s). Individual care plans should include consideration of a patient’s goals and priorities, as well as desired outcomes of care.

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_10 Care transition documentation practice improvements

Description :

Implementation of practices/processes for care transition that include documentation of how a MIPS eligible clinician or group carried out a patient-centered action plan for first 30 days following a discharge (e.g., staff involved, phone calls conducted in support of transition, accompaniments, navigation actions, home visits, patient information access, etc.).

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_11 Care transition standard operational improvements

Description :

Establish standard operations to manage transitions of care that could include one or more of the following:Establish formalized lines of communication with local settings in which empaneled patients receive care to ensure documented flow of information and seamless transitions in care; and/orPartner with community or hospital-based transitional care services.

Subcategory Name :

Care Coordination

Activity Weighting :

Description :

Establish effective care coordination and active referral management that could include one or more of the following:Establish care coordination agreements with frequently used consultants that set expectations for documented flow of information and MIPS eligible clinician or MIPS eligible clinician group expectations between settings. Provide patients with information that sets their expectations consistently with the care coordination agreements;Track patients referred to specialist through the entire process; and/or
Systematically integrate information from referrals into the plan of care.

Subcategory Name :

Care Coordination

Activity Weighting :

Description :

Ensure that there is bilateral exchange of necessary patient information to guide patient care, such as Open Notes, that could include one or more of the following:
• Participate in a Health Information Exchange if available; and/or
• Use structured referral notes.

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_14 Practice Improvements that Engage Community Resources to Support Patient Health Goals

Description :

Develop pathways to neighborhood/community-based resources to support patient health goals that could include one or more of the following:
• Maintain formal (referral) links to community-based chronic disease self-management support programs, exercise programs and other wellness resources with the potential for bidirectional flow of information; and provide a guide to available community resources.
• Including through the use of tools that facilitate electronic communication between settings;
• Screen patients for health-harming legal needs;
• Screen and assess patients for social needs using tools that are preferably health IT enabled and that include to any extent standards-based, coded question/field for the capture of data as is feasible and available as part of such tool; and/or
• Provide a guide to available community resources.

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_15 PSH Care Coordination

Description :

Participation in a Perioperative Surgical Home (PSH) that provides a patient-centered, physician-led, interdisciplinary, and team-based system of coordinated patient care, which coordinates care from pre-procedure assessment through the acute care episode, recovery, and post-acute care. This activity allows for reporting of strategies and processes related to care coordination of patients receiving surgical or procedural care within a PSH. The clinician must perform one or more of the following care coordination activities:
• Coordinate with care managers/navigators in preoperative clinic to plan and implementation comprehensive post discharge plan of care;
• Deploy perioperative clinic and care processes to reduce post-operative visits to emergency rooms;
• Implement evidence-informed practices and standardize care across the entire spectrum of surgical patients; or
• Implement processes to ensure effective communications and education of patients’ post-discharge instructions.

Subcategory Name :

Care Coordination

Activity Weighting :

Description :

The primary care and behavioral health practices use the same electronic health record system for shared patients or have an established bidirectional flow of primary care and behavioral health records.

Subcategory Name :

Care Coordination

Activity Weighting :

Medium

#IA_CC_17 Patient Navigator Program

Description :

Implement a Patient Navigator Program that offers evidence-based resources and tools to reduce avoidable hospital readmissions, utilizing a patient-centered and team-based approach, leveraging evidence-based best practices to improve care for patients by making hospitalizations less stressful, and the recovery period more supportive by implementing quality improvement strategies.